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Basic Fetal Monitoring Review. Ana H. Corona, FNP-C Nursing Instructor February 2009. Electronic Fetal Monitoring. Definition of fetal monitoring Method of assessing fetal status before and during labor Why is fetal monitoring important To provide insight that may affect fetal outcomes

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basic fetal monitoring review

Basic Fetal MonitoringReview

Ana H. Corona, FNP-C

Nursing Instructor

February 2009

electronic fetal monitoring
Electronic Fetal Monitoring

Definition of fetal monitoring

Method of assessing fetal status before and during labor

Why is fetal monitoring important

To provide insight that may affect fetal outcomes

Information is recorded on graph paper

Information is permanent part of the maternal medical record

Information is retrievable for litigation

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normal assessment findings
Normal Assessment Findings

FHR between 110-160 in gestations 32-40+ weeks

Rates slightly above 160 are normal in gestations less than 32 weeks.

Regular rhythm

Increases in the FHR associated with fetal movement that return to original rate range

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electronic fetal monitoring clarification
Electronic Fetal Monitoring Clarification

Information for students is for educational purposes only

Students should not assume any responsibility for interpretation of fetal monitor tracings

It takes months to years of experience to be prepared to interpret fetal monitor tracings

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methods of electronic fetal monitoring
Methods of Electronic Fetal Monitoring
  • External
    • Noninvasive method
    • Utilizes an ultrasonic transducer to monitor the fetal heart
    • Utilizes the tocodynamometer (toco) to monitor uterine contraction pattern

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methods of electronic fetal monitoring1
Methods of Electronic Fetal Monitoring
  • Internal Fetal Monitoring
    • Invasive
    • FHR is monitored via a fetal scalp electrode
    • Uterine activity is monitored by an intrauterine pressure catheter (IUPC)
  • A combination of external and internal fetal monitoring is common practice

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advantages and disadvantages of internal fetal monitoring
Advantages and Disadvantages of Internal Fetal Monitoring

Advantages

Patient can move without much interference in data transmission

More accurate measurement of data

Data less likely to be affected by artifact

Disadvantages

Invasive

Membranes have to be ruptured and cervix dilated

Application requires more skill

Procedure is uncomfortable for the mother

Risk of trauma and infection for mother and fetus

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components of the fetal monitor paper tracing
Components of the Fetal Monitor Paper Tracing

Strip has two components

Upper graph - records FHR data

Small squares represent 10 bpm increases as well as 10 seconds duration

Lower graph records contraction data

Small squares represent 10 second duration or 10 mmHg intensity

Dark line to dark line represents one minute of time

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baseline fhr
Baseline FHR

Normal baseline FHR in a term fetus 37 completed weeks or more is 110-160 bpm.

Determination of the baseline FHR is done between contractions

Baseline is rounded in increments of 5 bpm example; if the FHR is running 125-135 then the baseline FHR should be documented as 130

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fhr variability
FHR Variability

Normal changes and fluctuations in the FHR over time.

Best assessed between contractions

Considered to be the best indicator of fetal well-being

Variability can be influenced by hypoxic events, maternal hemodynamic issues, drugs, etc.

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examples of variability
Examples of Variability

Absent: Not detectable from baseline

Minimal: Less than 5 bpm from baseline

May occur with:

normal fetal sleep patterns

mother has received analgesia for pain

Moderate : 6-25 bpm from baseline (optimal pattern)

Marked: More than 25 bpm from baseline

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how do uterine contractions affect fetal heart rate
How Do Uterine Contractions Affect Fetal Heart Rate? 
  • Can affect FHR by increasing or decreasing the rate in association with any given contraction. 
  • 3 primary mechanisms by which UCs can cause a decrease in FHR
  •          Fetal head
  •          Umbilical cord
  •          Uterine myometrial vessels
periodic and episodic fhr characteristics
Periodic and Episodic FHR Characteristics

Periodic: Refers to changes in the FHR that occur with or in relationship to contractions

Episodic: Refers to changes in the FHR that occur independent of contractions

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examples of periodic changes
Examples of Periodic Changes
  • Variable decelerations: Result from some type of cord compression.
    • Nuchal cord, True knot
    • Decreased amniotic fluid

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severe variable decelerations
Severe Variable Decelerations

Note the depth from the baseline

Baseline

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early deceleration
Early Deceleration
  • Occur as a result of vagal stimulation to the fetal head during contractions which push the fetal head toward the pelvis.

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late decelerations
Late Decelerations
  • Occur in response to utero-placental insufficiency. Blood flow to the fetus is compromised and there is less oxygen available to the fetus)

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late decelerations with absent variability
Late Decelerations with Absent Variability
  • Note the smoothness of the FHR pattern
  • Decreased FHR caused by utero-placental insufficiency
  • Compromised blood flow to fetus

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prolonged deceleration
Prolonged Deceleration

Deceleration of the FHR from the baseline lasting more than 2 minutes but less than 10 minutes.

No explanation for why these occur

Commonly associated with uterine hyperstimulation.

Can also occur without any uterine activity

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example prolonged deceleration
Example Prolonged Deceleration
  • Note the duration of the deceleration lasts more than 2 minutes.

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fhr accelerations
FHR Accelerations

Are the most common type of FHR changes

Are abrupt changes and will increase from the baseline 15 bpm lasting 15 seconds before return to the baseline in a healthy gestation more than 32 weeks.

Less than 32 weeks increases of 10 bpm lasting 10 seconds are indication of a well oxygenated fetus.

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example accelerations
Example Accelerations
  • Note the increase from the fetal heart baseline

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sinusoidal pattern
Sinusoidal Pattern
  • Persistent wave variation of the baseline only seen in about 2% of patients.
  • Related to severe fetal anemia, hypoxia, or acidosis.

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uterine activity assessment
Uterine Activity Assessment

Periodic tightening and relaxing of the uterine muscle.

Pituitary gland is triggered to release a hormone called oxytocin that stimulates the uterine tightening.

Difference in Braxton Hicks contractions and true labor is the strength of the contractions and the changes in the cervix.

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characteristics of contractions
Characteristics of Contractions

Frequency: How often they occur? They are timed from the beginning of a contraction to the beginning of the next contraction.

Regularity: Is the pattern rhythmic?

Duration: From beginning to end - How long does each contraction last?

Intensity: By palpation mild, moderate, or strong.

By IUPC intensity in mmHg

Subjectively: Patient description

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segments of contractions
Segments of Contractions
  • Increment: Beginning, building of pressure
  • Acme: Most intense part of the contraction
  • Decrement: Diminishing of the contraction
  • Rest: Period of time between contractions
assessment of contractions
Assessment of Contractions

Palpation: Use the fingertips to palpate the fundus of the uterus

Mild: Uterus can be indented with gentle pressure at peak of contraction

Moderate: Uterus can be indented with firm pressure at peak of contraction

Strong: Uterus feels firm and cannot be indented during peak of contraction

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slide30

Variable decelerations in FHR during labor are severe dips occurring at the peak of contraction. This FHR problem is associated with which one of the following conditions?

  • Utero-placental insufficiency
  • Fetal head compression
  • Uterine insufficiency
  • Pressure on the umbilical cord
answer is d
Answer is D
  • These decelerations are common during labor.
  • The FHR drops during the contraction resulting from stimulation from chemoreceptors and baroreceptors as the cord is compressed.
  • The nurse should recognize these readings on the fetal monitor as normal.
slide32

A nurse is caring for a client in labor and is monitoring the FHR patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate?

  • Document the findings and tell the mother that the monitor indicates fetal well-being
  • Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen.
  • Notify the physician of the findings.
  • Reposition the mother and check the monitor for changes in the fetal tracing
answer is 1
Answer is 1
  • Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement.
  • Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.
slide34

A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client’s abdomen. After attachment of the monitor, the initial nursing assessment is which of the following?

  • Identifying the types of accelerations
  • Assessing the baseline fetal heart rate
  • Determining the frequency of the contractions
  • Determining the intensity of the contractions
answer is 2
Answer is 2
  • Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur.
  • Options 1 and 3 are important to assess, but not as the first priority.
slide36

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?

  • Early decelerations
  • Variable decelerations
  • Late decelerations
  • Short-term variability
answer is 21
Answer is 2
  • Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus.
  • Early decelerations result from pressure on the fetal head during a contraction.
  • Late decelerations are an suggests utero-placental insufficiency during a contraction.
  • Short-term variability refers to the beat-to-beat range in the fetal heart rate.
slide38

The physician asks the nurse the frequency of a laboring client’s contractions. The nurse assesses the client’s contractions by timing from the beginning of one contraction:

  • Until the time it is completely over
  • To the end of a second contraction
  • To the beginning of the next contraction
  • Until the time that the uterus becomes very firm
answer is 3
Answer is 3
  • This is the way to determine the frequency of the contractions
slide40

When monitoring the FHR of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:

  • An acceleration
  • An early elevation
  • A sonographic motion
  • A tachycardic heart rate
answer is 11
Answer is 1
  • An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate.
  • A tachycardic FHR is above 160 beats per minute.
which of the following findings meets the criteria of a reassuring fhr pattern
Which of the following findings meets the criteria of a reassuring FHR pattern?
  • FHR does not change as a result of fetal activity
  • Average baseline rate ranges between 100 - 140 BPM
  • Mild late deceleration patterns occur with some contractions
  • Variability averages between 6 - 10 BPM
answer is 4
Answer is 4
  • Variability indicates a well oxygenated fetus with a functioning autonomic nervous system.
  • FHR should accelerate with fetal movement.
  • Baseline range for the FHR is 120 to 160 beats per minute.
  • Late deceleration patterns are never reassuring, though early and mild variable decelerations are expected, reassuring findings.
references
References
  • AWHONN Clinical Position Statement
  • P. Burroughs, MSN, RN
  • Martin, E.J., (2002) Intrapartum Management Modules: A Perinatal Education Program. (pp 119-123). Lippincott Williams & Wilkins 3rd Edition.
  • Simpson, I., & Creehan, P. (2001) Perinatal Nursing 2nd Edition, (pp 379-383). Philadelphia, New York, Baltimore, Lippincott.

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